6100 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN .QNLY
BVI LDI NG PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMITA01 -•
Ouj BUILDING—ELECTRICAL-PLUMBING—MECHANICAL 6100
I OwBCH'S-• - W , - PLAN CHECK VALIDATION
Y NAME
is*
p ��py __�}x DTV. ELECTRIC PERMIT FEE
CiFS V R Q �.0 R 6 NONE sS-1 C6 ,
NAMEPAcroPs
OUTLETS-SWITCHES-RECEP 5.00/1.00
' r
uc.NO. LIGHTING FIXTURES 5,00/1.00
ADDRESS TOPS APPLIANCES-RESIDENTIAL '4.00
' PHONEPANELS ° - 5.00 • DATE OF APPLICATION
.I ARCHITECT - - 'PLAN CHECK FEE P.C.NO.
DP SIGNS 6.00
.ENGINEER
LIC.No. SIGNSTRANS: ' 3.00
H 09 ANDADDRESS ENG SPECIAL CIRCUIT 5,06 PERMIT VALIDATION
" :Zlp,: ITEMP.METER OR POLE INS. 15.00
ADRESS rs
ADDRESS MOTORS .SEE FEE SCH.
SERVICE CHANGE 10.00 - .,/
w¢ z .
-09
'LICIyNSEU CON'1'RACfORS DECLARATION , - d
a v w . I hereby affirm that I am Ilcenscd'Ruder go,osim,s of Chapter 9 -
w a y ( nunencing with Section 70001 of Division 3 of the Business and _ IS DANCE DATE
BLDG. EL
coECT. PLG. MCH.
R m 2 Prolessians CmIB,and my license is in full foree and effect. ❑ ❑ ❑ ❑E
o 0 m o License Class Lie.Number
Date Contractor '_
aBE •BUI BUILDING PERMIT a
r 0 w a OWNIi R-BUILDIiR DIiCLARATION - "
w °' U MISC.—. REFER TO ORD INFORMATION '1
g u -'I hereby'affirm tluv I am exempt from the Contractor's License
LL O a
Law for the following reason.(Sec.7031.5,Businessand Professions -ISSUANCE- _VALUATION , $/FT. .
r - PERMIT. 6.00 --� -
mon t Code:Any city orcounty which requires a permit to construct, ) �,p��
a O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. y sw
IF requires the applicant for Such Permit to file a signed statement that ., TOTAL. '\ -
a w
hContractor's a e is licensed pursuant to the provisions of the Contrner's License PERMIT TO 4.7 t
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3 of the (t
4 o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
M I- m the basis for the alleged exemption.Any violation of Seclion 7031.5 STORIES TYPE CONSTR.
, u3 _ by any applicant for a permit subjects the applicant to a civil penally ALTERDRAIN&VENT-WATER (EA.)of But more than five hundred dollars($500f): - '
❑ I,as owner of the property,or my employees"will,wages as 1ACK FLOW PROT ECT. DEVICE 2.00. 'OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF;'AR EA,CON D. 4.00 '
Code:The Contractor's License Law does not apply to an owner of
properly Sell.builds an Improves thereon,and who does such work FIXTURES-PER TRAP.' 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE.
�^ himself re through his own employees,Provided that such imprd0e-
ments not ended or withinoffered
onefor
year o If,however,the building GAS-EA.SVSTEM-I1NC.40UTLETS 4,00
or Improvement will have
sold within one year of completion,the owner, AS.EA.SYSTEM-OVER 4(EA.) .1.00 BUILDING USE
builder will have the burden of proving 01st he did not build or im- Ca
prove for purpose of sale.).
REST INDUSTRIALWASTE.INTER. - 20.00 IND CON PB Omer
❑ I,as owner of the properly,am exclusively contracting with ,O El El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-t ING5 V.B. 5.00 ASSESSORS PARCEL No.
and Professions Code:*I he Contractor's License I,aw does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS`-'OVER*5 IEA.) 1.00 •'
'contracts for such projects with a conlracloam s)licensed pursuant to "
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
rlam exempt under See ,B.&P.C.for tlli$ WATER HEATER W/VENT '4.00 _
e
Own Dmc9 ' WATER SYSTEM 4.00 ' ACC.DATE ACC.FILE NO.
RKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I.have a certificate afconsent to self-insure. "
or a certificate of Workers'Compensation Insurance,or a certifiedZONING ENG.SITE NO.
copy thereof(See,3800,LubpJ.,
Policy No. Company -
O ❑ Certified Copy is hereby furnished. FIRE$PRINK ENERGY T 24
Z Z ❑ Certified copy is filed will, the city inspection division.
FO APPlicant MISC.- p ' - REF,ER.TO ORD. ».v � . .N� v,[:]. N�
PERMITISSUANCE 6.00
Lu h CERTI EICA COI P NHX 17M ATIOTINS FROM WORKIiRS' PLOOO zoNE q.L.u.C.
W COMPENSATION INSURANCE PLG,CONTE. LIC.NO. 7 LG.
CL O (This sect Linn Dal not be completed if the permit is fill'onu _ TO
TAL
Z hundred dollars($100)or
U O .1 certify that in the performance of the work for which this-per- OTY. ♦MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation laws of California.
Q. Date - Appbcam - ALTER OR ADD TO MECH, q,Op BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of IN.
♦— Z 'mnplion,you should become subject to the Workers Compensation APPLIANCE..- ' 4.00 PLAN CHECK
provisions of the Labor Code, you must for0,with,comply.with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 3.00
.
'
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,000O 'F Z7F.M.15.00 SEISMICEE y !j%,
I hereby affirm, that Omre is a construction lending agency for EXHAUST HOOD (WITH DUCT) 200
th .
e performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name _
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 'ELECTRIC '
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 .
'in lbrmution is correct. I agree to comply with all city andrucounty g01LER-.COMP(3I).P or 100,000 B.T.U.) 4.00 PLUMBING -
ordinances and state laws relating to building construction, and
honey authorize representatives tat sins of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above hereby authorize
property for inspection purposes.
(We) agree to save,'indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the 'PERMIT ISSUANCE - 3.00 '
gmnli,lg nl lllis petmiL P V MECH:CONT:" LIC.NO. MECH.
q ? (gtl rorALTOTAL
Igo, are of Applicant/Contractor .D to
'OFFICE COPY